1. Spend the first hour or two after birth relaxing in a semi-reclined position with your baby skin-to-skin. Baby's front should rest against your body. All baby's body parts should be in contact with you or resting against a pillow. Babies don't like their legs dangling in the air! The semi-reclined position works well for twins.
C-section moms can ask the operating room nurse to place the baby skin to skin on your chest, and cover the baby with a blanket. Dad or other support person needs to be beside you to ensure baby does not roll off your chest while you are on the operating table. Many times, babies will latch and breastfeed even before surgery is completed!
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| Semi-Reclined Position. This baby is in a "onesie". Skin to skin is best accomplished with baby wearing a diaper only. If mom perceives the room is to cool she can have someone adjust the thermostat and/or place a light blanket over the baby. Drawing courtesy of La Leche League International. |
The time immediately following delivery is very important for mom and baby (with dad, too) to get acquainted and for baby to breastfeed. (Some of the reasons have been presented in earlier blogs.) The nurse can explain to other family members waiting outside your room what your are doing and why it is recommended. This way, you won't have to deal with any pressure yourself. Of course, if you want to have other family members join you, you can do so. However, many new mothers are uncomfortable having others around them when their breasts are so fully exposed.
Whatever you decide, baby should stay on you and not be passed around for others to hold at this time. There will be plenty of time for others to hold the the new family member later.
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| The Semi-Reclined position and different positions for baby while mom is semi-reclined. Drawings courtesy of La Leche League International. |
Routine newborn procedures can be delayed for a couple of hours until baby has breastfed. Hospital policies seem to try to trump what research has taught us. Still, you are a health care consumer and the baby's mother. As long as your baby have no immediate problems which require medical intervention, keeping baby on you, and allowing him or her to breastfeed is the BEST thing to do at this time for you and for your baby.
Giving the best care for the patient should be the goal of every health care professional. Let your labor nurse know your plans for the first hour or two after delivery as soon as you arrive at the hospital. Always be courteous, but you may also have to repeat your intentions until the message is understood and accepted.
2. In those first days, watch for feeding cues. Breastfeed right away and don't wait until your baby begins crying to feed him or her. Babies become "disorganized" and will tire quickly. When they do get to the breast, they will often nurse a short while and then fall asleep. Baby's blood sugar can drop, making baby sleepier. This can cause delay in feeding, starting a downward spiral.
If you put your baby to breast as soon as you notice the feeding cues, your baby will give you its best feeding. Signs that your baby wants to breastfeed are: baby sucks or smacks its lips, brings his hand to his mouth and begins to try to suck on it, i.e."rooting". She may try to find "the nipple" while someone else is holding her.
Keep in mind that this recommendation is for the first few days, or perhaps week or so. Once your baby is consistently nursing well, and gaining weight well, you can wait a bit if you need to to feed the baby -- but don't wait too long!
Avoid pacifiers until your milk supply is well established, your baby has mastered breastfeeding and is growing well. Most breastfeeding experts recommend 4 weeks of "mama only". After that, pacifiers don't seem to interfere with breastfeeding as much. (There can be other problems with long term pacifier use. Talk with your baby's doctor or do some online research).
One problem with the early introduction of pacifiers is that the baby will be less likely to give you feeding cues. Instead, he or she will just suck harder and more frequently and wait until hunger leads to crying. At this point, your baby may not feed as long or as well. The time delay on feedings can add up over the day and a feeding or two may be missed completely. Your milk supply can suffer. Your baby may loose more weight than he or she should.
There is one exception for the normal newborn with regard to pacifiers. Studies have shown that giving baby boys a pacifier during circumcision provides comfort. The stress hormones in the baby's blood are lower when they have the pacifier than when they do not. Once your baby is brought back to you, remove the pacifier and put it in your bag. Offer your breast for comfort. You can bring the pacifier out and give it to him after about 4 weeks, if you think it is necessary at that time.
When breastfeeding a newly circumcised baby boy, remember to place a large amount of the petroleum jelly provided by the hospital on the site of the circumcision. This will decrease pain from pressure or urination, and allow him to focus on breastfeeding better.
Newborn's have a very small stomach which slowly enlarges over the first month. A baby who is a day or two old will take in about 1 teaspoon at a feeding since this is what his or her stomach will hold. That means they may be nursing a LOT -- up to twelve to fifteen times a day during the first few days. They definitely need at least eight feeding a day, beginning on day two (they can sleep a lot on day one, especially if mom had medications for pain in labor).
Sometimes babies will "cluster feed". This means they will feed frequently for a period of time, and then take a nice long nap, up to five or six hours.
As long as your baby is nursing well at least eight times a day, and is peeing and pooping as he or she should for that day, enjoy the nap -- and try to get one for yourself. However, if these parameters are not being met, go back to skin to skin time. and attempt to feed your baby every two to three hours. Keeping a log of feeding and pees and poops will help you know when to wake your baby for a feeding. Most hospitals have one they give to all nursing mothers. If you would like to see a sample, click on
http://www.freeprintablemedicalforms.com/preview/Baby_Feeding_Schedule
Let your baby breastfeed as long as he or she desires, but if the feedings are taking longer than 45 minutes, ask the lactation consultant or nurse to evaluate baby at the breast. As your baby grows, you will see, even in the first weeks, that he or she won't feed as often. Many become more efficient and can feed in a shorter period of time.
The time you invest in best practices for breastfeeding success in those first days and weeks will have big payoffs in time and money saved later on -- plus your baby will become smarter and healthier by the day!
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Photo/Chart is by Katie Wickham BScN, RN, IBCLC, BCLS of Babies First Lactation. Used with permission. |
3. Spend lots of time skin to skin with your baby. The more your baby lies against your chest, the more quickly your milk supply will increase, and baby's intake will grow. Your baby will be calmer. His or her heart rate and breathing, and also blood sugar levels, will be more stable. Just having your baby skin to skin increases your output of oxytocin, an important hormone for breastfeeding, for bonding, and for keeping your healing uterus nice and tight to minimize blood loss. Neat design, huh? What a wise God to take care of the "details".
If you begin to feel sleepy, wrap your baby in a blanket and give him or her to an awake, alert, adult, or put the baby back in it's bassinet. Floors in hospitals are hard and babies don't do well if they fall onto the floor from the bed!
Be careful with visitors. Without meaning too, they can interfere with your skin to skin time and with breastfeeding itself. Just remember that you and baby come first. Visitors will go home and sleep all night. You can't. Make a plan now on how you will manage the most important things.
4. Make certain your baby has achieved a deep and comfortable latch. If you feel pain or pinching, the latch is not correct. Remove your baby in order to let him or her re-latch. To do this in a way which protects your nipple and keeps it from being damaged by the baby's clenched gums, place your finger, with the nail trimmed short, into the baby's mouth, AND BETWEEN THE GUMS. HOLD YOUR FINGER THERE while removing your baby.
Another, and gentler, way to completely break the latch is to lay your finger along the side of his or her mouth. Pointing your finger from chin to nose, or nose to chin. Press down against your breast and wait for the baby to "pop off" (see link below). Always protect your nipple! If this technique does not work, then use the previously described one.
Allow the baby to latch again as many times as necessary to get a deep latch. A shallow, or "nipple" latch, often leads to nipple soreness and injury. In addition, your baby won't get as much milk.
Be patient. Your baby will learn from his or her trial and error to open wide and latch deeply to be allowed to stay on the breast and get the milk!
There are many good books and online video clips to help you understand what makes a good latch. You can see a what a good latch looks like, and also the "pop off" technique by going to http://newborns.stanford.edu/Breastfeeding/FifteenMinuteHelper.html
Even with proper latching, you may still feel a little nipple tenderness in the first few days. If so, rinse your nipples with cool water (NO soap), pat them dry, express a little colostrum or breast milk, and gently rub it on your nipples. If this does not help, then rub a little anhydrous lanolin onto your nipples after rinsing them and patting them dry. The reason for the rinse is that saliva is a digestive fluid. You don't want a digestive fluid on tender nipples which might be microscopically abraded. Healing should occur faster with the rinse and application of the breastmilk, or if needed, lanolin.
For nipple pain beyond mild tenderness, have a lactation consultant examine your breasts, observe a latch, and so on. She should be able to identify the cause of the injury and recommend the appropriate measures to take for healing and prevention of additional injury.
5. Keep track of your baby's wet and soiled diapers to make certain he is getting enough milk. One wet and one poopy diaper is expected on Day 1, two wets and two poops on day 2, etc. One Day 5 there should be six wet diapers and four or five poops.
The thick, tarry, stool, called "meconium" should be passed in the first 24 hours. The stool begins to change color over the next 3 to 4 days (blackish green to green to greenish yellow to yellow). You can see "poop progression pictures" at http://www.breastfeedingmaterials.com/view-breastfed-baby-stool. The photos are not pretty, but they are very helpful in understanding what the poop of a breastfed baby should look like.
Many moms think the baby has diarrhea, but normal yellow stool can be runny, and is usually somewhat loose. Again, the following link has an example of a feeding, wet, and messy diaper log. http://www.freeprintablemedicalforms.com/preview/Baby_Feeding_Schedule
6. If supplementation becomes necessary it can be given with WITHOUT using a bottle. But first, lets take a look a a fairly common reason for supplementing -- too much weight loss.
Babies come with about 10% to 15% extra fluid at birth. This prevents dehydration during the first 3 or so days, until mom's transitional milk comes in. As the babies fluid level begins to drop, thirst, as well as hunger, begins to drive his or her desire to nurse. This "happens" to occur just about the time mom's "milk supply" comes in. If baby is nursing well and frequently, then mom may feel "full", but does not become "engorged". Engorgement, though common, is not "normal". It is more likely to occur if baby is not feeding frequently or well. This can be caused by the effects of labor medications, missed feeding cues, lack of skin to skin contact, and formula supplementation.
Most hospitals will note when baby looses 7% of its birth weight. The doctor will prescribe supplementation (mom's milk or formula) for the baby with a 10% weight loss. One problem with this protocol is that some babies have a LOT of extra fluid on board at birth because mom was induced, was given Pitocin, lots of IV fluids, or had a C-section with IV fluid. Instead of the typical 10% to 15%, the baby could have 20%, more or less.
A recent study indicated that babies diuresed (peed off) the overload fluid in the first 24 hours. The authors suggested that the baseline weight for the baby be taken at 24 hours post-birth. This diuresis of extra maternal IV fluid in the baby, in addition to normal weight loss in the first few days, can put the total weight loss at 10% very quickly. Thus, a perfectly healthy and normal baby may be subjected to the risks associated with formula feeding when, in reality, once the mother's contribution to baby's fluid load has been taken into consideration, the baby would not need the formula.
If this happens to your baby, do the following:
* Talk with the doctor before allowing any supplementation.
*Discuss your labor and birth experience. If you had a lot of IV fluids, or IV fluid within 2 hours of delivery, let the doctor know.
*Look at your own body. Are you feet and legs still swollen? Have your breasts been swollen (sometimes to the point it is hard for the baby to latch)? Mention this to the physician.
*Evaluate the baby. Has the baby been feeding well? Are the pees and poops normal? Does the skin, and the mucous membranes of the eyes and mouth look normal?
*If any blood sugar readings were taken, were they normal? Were they correctly done? Only a lab test can confirm low blood glucose (sugar) readings.
If everything mentioned above checks out OK, then ask the doctor if supplementation could be delayed for 12 hours, and continue to observe the baby. A dehydrated baby has signs of dehydration. Also, a lactation consultant can observe and assess a feeding session. She can do a pre-and post feeding weights of the baby to confirm milk transfer (special scales are required for this, so it may not be readily offered).
If supplementation is required for a medical reason, consider the following:
*the size of the baby's stomach
*using your own milk for supplementing
*feeding with another device instead of using a bottle.
One formula company helped to fund a study which showed that "supplementing 10 ccs of formula increased the success of breastfeeding". Of course, the trumpets came out and formula was once again declared to save the day.
In reality, the study should have reported that LIMITING formula supplementation to 10ccs increased breastfeeding success. When babies are supplemented, they are often given significantly more than 10 ccs, affecting their desire to breastfeed. By limiting formula supplementation, babies were more likely to go back to breast.
If you begin using hand expression in addition to breastfeeding on Day 1, you milk supply will increase more quickly. This colostrum can be given to the baby via a spoon or medicine cup right then. The lactation consultant, and possibly your nurse can show you how.
Express your milk for a few minutes 5 times a day, after or between feedings. Ask the nurse for a small container to store the milk in if your baby is asleep and not ready to take the colostrum. You can feed it to him or her at another time. You won't get much more than a "puddle in the middle" of a plastic teaspoon at first (may 2 to 3 mls -- 5 mls equals one teaspoon). That's OK. Every session builds your supply. If your baby is not nursing well, you can begin giving it to her to keep her blood sugar levels normal. If supplementation is required, you will have more milk to when you express milk for that feeding.
If you have been advised to pump for any reason, incorporate hand expression into your schedule. One study found that by adding hand expression five times a day to the regular pumping schedule, women produced more milk. To learn how to do hand expression, go to http://newborns.stanford.edu/Breastfeeding/HandExpression.html
If you are asked to pump on Day 1 or 2, you may not get any milk out. This does not mean you do not have any milk. It means the pump is not designed like a baby or like you hand. It can not get out the smaller amounts of colostrum in mom's breast. A few moms will have a larger amount of colostrum, and the pump may be able to remove some at the first session. The next sessions may not yield any results until mom's transitional milk supply begins to comes in. Do not become discouraged if the pump can not remove milk in the first day or two. This is normal.
Women who have had a C-section may experience a delay in producing more colostrum and then transitional milk. So might women who lost a lot of blood, or women with endocrine disorders like diabetes or PCOS. Do everything you know that will help with your supply: skin to skin, hand expression, frequent feeds, pumping, etc.
If supplementation is required, and you do not have enough milk to express at the time, formula is available, and is preferable to cows or any other type of milk alone. Some hospitals have pasteurized human milk from a milk bank. You can ask if it is available. If so, request it. It can be expensive, so you will have to see if your insurance will cover it. If not, you will have to decide is you want to pay the extra amount required for it.
Once your colostrum begins transitioning toward mature milk (around day 4), and your baby is feeding well (least eight times in a 24 hour period), you can discontinue the hand expression.
7. When you are ready to try upright positions for breastfeeding, start out with the cross-cradle hold and the football/clutch hold. Wait until your baby can breastfeed well before using the commonly seen cradle hold. Most new babies do not have the head control required to latch correctly and maintain a deep latch while in the cradle hold.
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| Drawings Courtesy of La Leche League International. For more illustrations or info click on the link below: |
Here are some tips for using the upright positions:
* Do not put your hand behind the baby's head! This can push his chin toward his chest. This makes it difficult for your baby tomaintain a seal or to swallow. Place your had at the nape of your baby's neck (as shown above) with your palm between his or her shoulders. Your fingers will rest lightly against its jaw/side of face/side of head. This will allow your baby to adjust his or her head into a comfortable position for nursing.
*In most cases, in the early days, it is a good idea to continue to support your breast from underneath while the baby is latched. A newborn may have difficulty maintaining a deep latch if the weight of mom's breast is more than baby can manage. In this case, the breast begins to slide toward the front of baby's mouth, and breastfeeding has become "nipplefeeding" -- the deep latch becomes too shallow.
*Use as many pillows as it takes to support your arms in a comfortable position while you are sitting upright. If you hold your baby and your breast without pillow support, your arms may begin to tire, causing the baby to slowing slip down from a deep to a shallow latch.
*Ask an LC or nurse to work with you when you try upright positions. They can evaluate how things are going and may any necessary suggestions for your comfort and baby's latch.
*Avoid pressing down very far on your breast to clear baby's airway. Baby's were designed with flat noses so they can breath when "smooshed" at mom's breast (Ah, the details considered by our wise God!). If your healthy baby can't breath, he or she will pull away of break the latch to breath. If you see this occurring, latch your baby, and then press on the baby's diaper area with the arm that holding the baby. This will help bring his or her head back to clear the airway. If your baby continues to breastfeed, even if you can not see the airway he is clearly getting air. When a mother presses down too much on her breast so she can see the airway is clear, it can tilt her nipple up toward the roof of her baby's mouth, and cause some abrasions on the tip of the nipple. It also can cause a deep latch to become a shallow latch.
8. Always work with a lactation consultant, a Le Leche League Leader, or another breastfeeding expert if you have any problems. If you try to figure it out on your own, you may not be successful. Then, trying to make it work becomes harder. Many moms are simply tired at this point and reach for the formula bottle.
9. Some mothers plan to pump and breastfeed. This is better than formula feeding, but it is hard to do over the long term. Babies are made to maintain and increase mom's milk supply. Pumps lack some of the things babies do in this area. Also, it takes longer for mom to make antibodies for the baby if a baby has picked up a germ.
If the baby breastfeeds, the germ transfers to mom's body via the breast. She starts making antibodies, which go back to the baby in her milk, sometimes even during that same feeding This protection process can be delayed with pumping and bottle feeding. Plus, it takes twice as long to pump and then bottle feed, unless someone else always gives the bottle. If mom is doing all the work, she has to be very dedicated!
If you decide that pumping and bottle feeding is what you need or prefer to do, then you will need to rent a hospital grade pump. Using a pump designed for use three times a day or less may not work as well. A hospital grade pump, along with a double pumping kit, will help you build and maintain your supply longer. Double pumping saves time and also can increase the release of prolactin, a milk making hormone.
You will need to pump during each time the baby would be coming to breast. Pumping once during the night in the early week increases the levels of prolactin in mom's body, which increases milk supply. With diligence, many women can provide their milk for their babies for several months. Some can make it for a year or more. Don't forget that adding hand expression to the pumping, and spending time skin to skin with your baby can help you maintain and even increase your supply.
Understanding and applying the God designed basic principles of breastfeeding which have worked for women over history will promote your success with breastfeeding. Introducing some "modern day" interventions in this natural process can disrupt everything that hormones and common sense support. Those interventions include: unnecessary separation of mother and baby immediately after birth and during the first few days; placing a newborn on a "schedule" (a reflection of our modern society) instead of immediately responding to feeding cues; and introducing the artificial "teats" of pacifiers and bottle nipples. Anything which affects this intense mother-baby time, and the natural flow of the "breastfeeding dance" mother and baby learn in the early hours and days, can easily push successful breastfeeding off track.
Sometimes, medical issues arise which can interfere with the normal establishment of breastfeeding. WORK WITH THE LC in these cases. There are ways to keep mom's milk going, as well as ways to feed the baby so he or she will still be able to come to the breast for feedings at the appropriate time. Not all medical professionals are knowlegable or skilled protecting breastfeeding in these circumstances. The LC will be a great resource of information and support.
One such medical situation which occasionally occurs is "tongue tie". We are learning more about this minor, yet disrupting, anomaly. There are different types of tongue tie. They present themselves differently in the baby's mouth and in feeding efforts. Tongue ties (also known an ankyloglossia) occur when the membrane which connects the tongue to the floor of the mouth is too short and keeps the tongue from executing its full range of motion and also from full extension. Baby is not able to cup the nipple or hold a seal at the breast. Some ties are easy to identify while others are not.
An LC might suspect (or even know for certain) there is a tongue tie, and the pediatrician may think one does not exist in the baby. What can follow is a prolonged period of nipple soreness for mom and inadequate weight gain ("failure to thrive") in the baby. This is due to less than normal milk intake because of sucking issues caused by the tie. The following link goes to a site which provides good information and photos which might be helpful for the mother to share with the physician: http://cwgenna.com/quickhelp.html. Local Le Leche League groups can often recommended physicians who are knowledgeable about correctly diagnosing and treating tongue ties.
During your pregnancy, do not be afraid to chart your course for early breastfeeding with your care providers, your family, and your friends. Of course, use wisdom in making decisions of medically necessary interventions. Watch out for "routines" which may possibly be easier for hospitals in managing patient care but which actually are not the best practice for you and your baby. Plan in pregnancy to incorporate actions in labor, delivery, and immediate postpartum which will minimize breastfeeding problems (see previous post).
Pray for wisdom and support, and for an easy and natural transition into the "4th trimester". Your baby has been very close to your body for nine months. There is no evidence that training a newborn to be separated from mom is beneficial. You baby will learn to adapt to increasing intervals of separation. By the time your baby is three months old (the end of the 4th trimester) he or she will probably be very content to nap in the baby bed, enjoy play time in the arms of others, and so on.
As your baby grows, you can "pattern" feedings. An example of patterning feedings is to feed the baby more frequently in the evenings. This usually leads to longer stretches of sleep at night.
Don't get too involved with feeding schedules. Baby have growth spurts, get thirsty, and seek comfort. These things will not fit into a schedule.
Growth spurts occur when baby is about 3 weeks, 6 weeks, 3 months, 4 months, and 6 months of age. Your milk makes your baby grow to the point she needs more milk with her feedings. She will want to nurse more often for a few days. If you feed her when she wants to nurse, your milk supply will increase. She will return to her normal feeding routine, but with more milk filling her tummy.
Seek assistance and support from breastfeeding experts available near you, whether in the hospital or in the community. Other women who have successfully breastfed can be an invaluable source of support. Most of all, ENJOY this special time of your life as a woman.
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